Do Some Men Who Desire Sex Reassignment Have a Mental Disorder?
Comment on Meyer-Bahlburg (2010)

Archives of Sexual Behavior (2011) 40: 651-654

By Anne A. Lawrence, M.D., Ph.D.

In a review article written for the DSM-5 Gender Identity Disorders Subworkgroup,
Meyer-Bahlburg (2010) concluded that "the available empirical evidence does not permit
a categorical, universally valid statement that GIVs [gender identity variants] are or
are not mental disorders" (p. 472). To make a categorical, universally valid statement
about any class of abstract mental phenomena is an ambitious goal. I propose to address a
more limited question: Do some men who desire hormonal and surgical sex reassignment have
a mental disorder? I will discuss the following points:

It is useful to focus on the desire for sex reassignment, as opposed to variant
or disordered gender identity; by doing so, one can address the actual presenting
concerns of patients, rather than abstract concepts.

In the United States, Canada, and much of northern Europe, most men who seek or
undergo sex reassignment -- male-to-female (MtF) transsexuals -- are nonhomosexual relative
to natal sex. In many or most of these persons, the desire for sex reassignment reflects
a mental disorder, and the DSM-5 should include an applicable diagnosis.

Although the desire for sex reassignment historically has been conceptualized as
reflecting a disorder of gender identity, disordered gender identity in nonhomosexual
MtF transsexuals is an epiphenomenon, not the underlying mental disorder itself.
It would be helpful for the text discussion in the DSM-5 to emphasize this point.

It is understandable that Meyer-Bahlburg (2010) chose to focus on variant gender
identity -- specifically, on whether such an identity could sometimes be considered
disordered -- as the central issue in deciding whether persons dissatisfied with their
assigned sex, gender role, or sexed body characteristics might have a mental disorder:
All recent editions of the Diagnostic and Statistical Manual of Mental Disorders
(DSM; American Psychiatric Association, 1980, 1987, 1994, 2000), as well as the current
edition of the International Classification of Diseases (World Health Organization,
1992), have conceptualized these clinical concerns as disorders of gender identity.
Moreover, among adolescents and adults, a self-reported cross-gender identity is highly
correlated with symptoms such as anatomic dysphoria, gender role dysphoria, and the
desire for hormonal and surgical sex reassignment (Deogracias et al., 2007). Gender
identity is, however, a slippery, imprecisely defined concept with a variety of possible
meanings (Money, 1986; Ovesey & Person, 1973; Stoller, 1968). Significantly, Meyer-Bahlburg
never attempted to define gender identity. He also concluded that no adequate theory of
normal gender identity development had yet been proposed. Consequently, his painstaking
exploration of variant gender identities, their diverse manifestations, and the possibility
that such identities could sometimes be disordered, was inconclusive.

I will focus on a more specific question: Do some men who desire hormonal and surgical
sex reassignment have a mental disorder? By framing the issue this way, one can avoid
having to formulate a comprehensive definition of gender identity or address competing
theories of normal gender identity development. Focusing on the desire for sex reassignment
also ensures clinical relevance: People who are unhappy with their assigned sex or sexed
body characteristics often consult mental health professionals to request sex reassignment
(Meyer et al., 2001), whether or not they would describe themselves as having a disorder
of gender identity.

Most men who currently request or undergo sex reassignment in the United States, Canada,
and much of northern Europe are nonhomosexual (gynephilic) in sexual orientation (Lawrence,
2010). In these nonhomosexual MtF transsexuals, the desire for sex reassignment can be
understood as an outgrowth of autogynephilia: sexual arousal to the thought or image
of having a woman's body or otherwise resembling a woman (Blanchard, 1989a, 1989b, 1991,
1992, 1993a, 1993b; Lawrence, 2004, 2007). The evidence supporting this conceptualization
is extensive: Most nonhomosexual MtF transsexuals report a history of autogynephilic arousal,
whereas most homosexual MtF transsexuals do not (Blanchard, 1985; Lawrence, 2005).
Nonhomosexual cross-dressing men -- transsexual and otherwise -- who deny autogynephilic
arousal display such arousal when tested phallometrically (Blanchard, Racansky, & Steiner,
1986), suggesting that such arousal is almost universal in nonhomosexual transgender men.
Autogynephilic fantasies that involve having a female body, and female genitals in
particular, are more closely linked to the desire for surgical sex reassignment than
other autogynephilic fantasies (e.g., that involve wearing women's clothing; Blanchard,
1993a, 1993b). Desire for sex reassignment sometimes remits when a nonhomosexual man
becomes attracted to a new female partner, putatively directing his attention away from
autogynephilic fantasies and enactments (Blanchard, 1992; Marks, Green, & Mataix-Cols,
2000; Shore, 1984). Analogues of autogynephilia are found in men who desire limb
amputations and other profound physical transformations (Lawrence, 2006, 2009), some
of whom also desire sex reassignment. Most significantly, some men who desire sex
reassignment candidly acknowledge that their desire is an outgrowth of autogynephilia
(Lawrence, 1999a, 1999b). Accordingly, even skeptics who doubt that autogynephilia
accounts for all or almost all cases of desire for sex reassignment in nonhomosexual
men would have to concede that it accounts for many such cases.

Does the desire for sex reassignment in autogynephilic MtF transsexuals represent a
mental disorder? I contend that it does. To meaningfully address the question, one must
attempt to define the term mental disorder, an obligation that writers who discuss
this topic -- including Meyer-Bahlburg (2010) -- too often neglect. For purposes of
discussion, I will use the definition proposed by Wakefield and First (2003), in an article
cited by Meyer-Bahlburg; similar definitions have recently been proposed by Stein et al.
(2010) and First and Wakefield (2010). According to Wakefield and First, a mental disorder is
"a 'harmful mental dysfunction,' with harm being determined by social values and the word
dysfunction referring to the failure of a mental mechanism to perform its natural
(i.e., evolutionarily selected) function" (p. 28). Wakefield and First recognized that an
evolutionary analysis created potential epistemological challenges but argued that often
"one can judge with some plausibility the functions and dysfunctions of a [mental]
mechanism (or at least that a function or dysfunction likely exists), with no need
for detailed direct knowledge of the evolution of the mechanism." (p. 39). They added
that, in many cases, "one can make such inferences without knowing anything about the
actual mechanisms. . . . Indeed, many of the DSM's categories (e.g., sleep disorders,
sexual and gender identity disorders) clearly correspond to types of inferred designed
mechanisms that have gone wrong." (p. 36). Wakefield and First considered a dysfunction
to be harmful if it carried significant "negative implications for the individual's
overall well-being" (p. 34), or perhaps sometimes for the well-being of others (p. 41).
They also emphasized that the dysfunction must be "in the individual" (p. 34) and "cannot
be due only to social deviance, disapproval by others, or conflict with society or others"
(p. 34). Although Wakefield and First's definition may not be perfect, it provides a
starting point for discussion, and the analysis that follows is not highly dependent on
its specific details.

In autogynephilic MtF transsexuals, it is reasonable to infer that the mental mechanism
responsible for accurately "locating erotic targets in the environment" (Freund & Blanchard,
1993, p. 558) has failed to perform its natural function: Specifically, there has been a
partial or complete failure of the evolutionarily selected mechanism that keeps heterosexual
erotic interest (i.e., gynephilia) directed toward erotic targets external to the self.
Autogynephilic MtF transsexuals experience a powerful erotic interest in turning their
own bodies into facsimiles of their preferred erotic targets (females), an interest that
competes with and sometimes completely overshadows erotic interest directed toward external
female partners (Blanchard, 1992). It is easy to understand why evolutionary selection
might favor the development of a mental mechanism that would keep gynephilic men's erotic
interest focused on external female partners. When a gynephilic man's erotic interest is
instead directed primarily toward his own feminized body, one can reasonably infer that
this putative mental mechanism has wholly or partly failed. If the foregoing analysis is
correct, then the desire for sex reassignment in autogynephilic MtF transsexuals -- that
is, in many or most nonhomosexual MtF transsexuals -- represents a genuine mental dysfunction.

Is this mental dysfunction harmful? Does it cause significant distress or otherwise
significantly decrease the overall well-being of affected persons? Clinicians have observed
for decades that it does. Benjamin (1966) famously observed that "there is hardly a person
so constantly unhappy (before sex change) as the transsexual" (p. 66). Autogynephilic MtF
transsexuals, like other types of transsexuals, experience distressing feelings of being
"wrongly embodied." Prosser (1998) analyzed over 50 transsexual autobiographies, including
several by nonhomosexual MtF transsexuals, and concluded that "the image of wrong embodiment
describes most effectively the feeling of pre-transition (dis)embodiment: the feeling of a
sexed body dysphoria profoundly and subjectively experienced" (p. 69). Perhaps the strongest
evidence of the distress associated with this feeling of wrong embodiment is the
extraordinary efforts transsexuals make to change their bodies, including undergoing
expensive and often painful cosmetic and surgical procedures and even self-surgery in
some instances.

For autogynephilic MtF transsexuals, the distress of wrong embodiment reflects an
inability to actualize the intense erotic desire to have a female body. This can be
understood as analogous to the distress a normophilic man would feel if he were never
able to express or actualize his sexual desires. The sexed body dysphoria of autogynephilic
MtF transsexuals is clearly "in the individual"; although it may coexist with distress
caused by prejudice, discrimination, or unwanted gender role expectations, it is not
reducible to any of these and is not merely a result of social deviance, disapproval
by others, or conflict with society. If this analysis is correct, then many or most
nonhomosexual men who seek or undergo sex reassignment have a genuine mental disorder.
These individuals often benefit from psychiatric, hormonal, and surgical treatment of
their disorder (Meyer et al., 2001); the DSM-5 should include a diagnosis applicable
to them.

I have thus far avoided any detailed discussion of variant or disordered gender identity
per se, but it is difficult to ignore the issue completely, because the DSM has historically
conceptualized the desire for sex reassignment as representing a disorder of gender identity.
This paradigm is likely to be retained in the DSM-5, even if the term gender identity is
replaced by some euphemistic alternative, such as "experienced/expressed gender" (American
Psychiatric Association, 2010). But the accompanying text could and should discuss the
limitations of this paradigm. In particular, it should emphasize that disordered gender
identity in nonhomosexual men who seek sex reassignment is best understood as an
epiphenomenon, not the underlying mental disorder itself. In these men, the underlying
mental disorder -- the harmful dysfunction -- is a failure of the mental mechanism
that keeps heterosexual erotic desire directed toward erotic targets external to the
self. This dysfunction eventually leads to a cross-gender identity, but the latter is
a secondary, derivative phenomenon.

Before elaborating, I should make clear what I mean by cross-gender identity in
nonhomosexual MtF transsexuals. Historically, the term gender identity has been
used in two distinctly different ways. It is sometimes used to denote the fundamental
sense of being male, female, or of indeterminate sex that children develop at ages
18–30 months and that is usually immutable thereafter; Stoller (1968) called this
core gender identity. Nonhomosexual MtF transsexuals do not have a female or
cross-gender core gender identity: In childhood, during pre-transition adulthood, and
after sex reassignment, they know that they are, always have been, and always will be
biologically male. But gender identity can also denote one's current sense of oneself as
being psychologically male, female, or of indeterminate sex (Money, 1986). Ovesey and
Person (1973) distinguished between core gender identity and the later-developing type of
cross-gender identity found in transsexuals and transvestites, which reflects "an
individual's self-evaluation of psychological maleness or femaleness" (p. 54).
Nonhomosexual MtF transsexuals gradually develop cross-gender identities of this second
type, which they experience as incongruent with their core gender identities (Stoller,
1968).

In nonhomosexual MtF transsexuals, cross-gender identity can be considered an
epiphenomenon, because it develops years or decades after the mental dysfunction that
putatively gives rise to it has become apparent. In persons who will eventually become
nonhomosexual MtF transsexuals, a dysfunction in the mental mechanism responsible for
accurately locating erotic targets in the environment -- as evidenced by the onset of
erotic cross-dressing -- typically becomes apparent "just before, during, or after
puberty" (Whitam, 1997, p. 192; see also Blanchard, Clemmensen, & Steiner, 1987; Doorn,
Poortinga, & Verschoor, 1994). The development of a cross-gender identity in these men,
however, typically occurs decades after the onset of erotic cross-dressing and is usually
preceded by experiences of complete cross-dressing, public self-presentation while
cross-dressed, and adopting a feminine name (Docter, 1988). Docter proposed that
choosing a feminine name constituted "the most explicit statement that a cross-gender
identity has emerged" (p. 209). Based on his research with nonhomosexual MtF transsexuals
and other nonhomosexual cross-dressing men, many of whom also develop cross-gender
identities of some strength (Docter & Prince, 1997), Docter observed that:

Among our subjects, 79% did not appear in public cross dressed prior to age 20; at that
time, most of the subjects had already had several years of experience with cross dressing.
The average number of years of practice with cross dressing prior to owning a full
feminine outfit was 15. The average number of years of practice with cross dressing
prior to adoption of a feminine name was 21. Again, we have factual evidence indicative
of the considerable time required for the development of the cross-gender identity. (p. 209)

In short, autogynephilic eroticism, as evidenced by erotic cross-dressing, precedes
cross-gender identity by years or decades in nonhomosexual MtF transsexuals. These
transsexuals do not have female core gender identities, nor do they have well developed
cross-gender identities that precede and act as the driving force behind their desires
to turn their bodies into facsimiles of women's bodies. Rather, nonhomosexual MtF
transsexuals gradually develop cross-gender identities after years or decades of erotic
cross-dressing, accompanied by the autogynephilic wish to turn their bodies into facsimiles
of women's bodies. In this sense, cross-gender identity in nonhomosexual MtF transsexuals
is a secondary phenomenon or epiphenomenon. Emphasizing this point in the text discussion
of gender identity disorders in the DSM-5 would help to correct many misconceptions among
mental health professionals.